AGG Talks: Home Health & Hospice Podcast - Episode 9: The Impact of AI and Prior Authorizations on Home Health and Hospice
The CMS Interoperability and Prior Authorization Rules
New CMS program, WISeR, will leverage third parties to screen prior authorization requests using technologically enhanced processes....more
CMS announced the rollout of the WISeR (Wasteful and Inappropriate Service Reduction) model in June. It aims to use technologies like artificial intelligence (AI) to “ensure timely and appropriate Medicare payment for select...more
The last week of June was a busy one when it comes to news about prior authorization – a major tool used by health plans and the federal government to manage healthcare utilization. The week started with a commitment from...more
CMS recently announced a new model it will be using to pilot the use of artificial intelligence and machine learning in reviewing prior authorizations submitted for certain services CMS has identified as being at greater risk...more
Health plan members of AHIP and the Blue Cross and Blue Shield Association made news earlier this week when they announced a series of steps that a broad swath of health insurers will take to improve the prior authorization...more
The US Government Accountability Office (GAO) recently released a report on the Centers for Medicare and Medicaid Services (CMS)’s oversight of prior authorization criteria for behavioral health services (BHS) by Medicare...more
Last week, the Government Accountability Office (GAO) published a report determining that there is a nontrivial risk that prior authorization requirements, together with internal coverage criteria, may undermine the Medicare...more
Last week, the contract year (CY) 2026 Medicare Advantage (MA) and Part D final reg entered the clearance process at the Office of Management and Budget (OMB). As mentioned in a previous Regs & Eggs blog post, OMB’s review is...more
In this episode, AGG Healthcare attorneys Bill Dombi and Jason Bring discuss the role of managed care, artificial intelligence, and prior authorizations in home health and hospice. Bill and Jason examine a recent lawsuit...more
Traditional Medicare (Parts A and B) and Medicare Advantage (Part C, including additional vision, dental, and hearing benefits) plans aim to provide comprehensive medical benefits to American Seniors and adults with...more
Over the past two years, federal and state government agencies have moved to regulate the deployment of artificial intelligence (AI) in the healthcare setting, including in the utilization management (UM) and prior...more
With recent CMS mandates and state-level reforms, the healthcare industry faces a pivotal moment to improve prior authorization processes, ensuring timely access to care and integrating health equity considerations....more
On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) published an expansive final rule amending Medicare Advantage (MA) regulations related to, among other things, coverage criteria and prior authorization....more
When stakeholders think about prior authorization in the Medicare program, they usually focus on its use in Medicare Advantage (MA), and not how it is used in traditional Medicare. In fact, a few weeks ago, the Centers for...more
On 17 January 2024, the Centers for Medicare & Medicaid Services (CMS) released a final rule outlining new interoperability and prior authorization requirements for certain payors (Final Rule). With the adoption of the Final...more
I, JEFFREY DAVIS, RETROACTIVELY DECLARE THE MONTH OF JANUARY IN THE YEAR 2024 TO BE KNOWN AS “MEDICARE ADVANTAGE MONTH.” Obviously, I don’t have the power to do that, but the health policy community did see a lot of...more
On January 18, 2024, CMS released a pre-publication version of a final rule (the Final Rule) that will require Medicare Advantage organizations (MA or Part C), Medicaid and the Children’s Health Insurance Program (CHIP)...more
Last week CMS issued its final rule “CMS Interoperability and Prior Authorization” (CMS-0057-F), unchanged from its proposed rule in 2022, which addresses prior authorizations. Prior authorization, a “utilization management”...more
Prior authorizations, one of health insurers’ many “utilization management” techniques, is a hot topic amongst practicing physicians, patients, and regulators, to name a few. The prior-authorization process requires a health...more
In the Office of the Inspector General's latest report released in April of 2022, the denials of some prior authorization requests by Medicare Advantage Organizations (MAOs) raise concerns about beneficiary access to...more